Welcome to the Orthodontist

Welcome to Suliman Orthodontics
We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.
1. Tell Us About Your Child
Today's Date
MaleFemale
Child's Name*

LastFirstMI
Nickname
CHILD PREFERS TO BE CALLED
SS#
Child's Birthdate

MonthDayYear
Child's Age
School:
Grade
Child's Home #

Area CodePhone Number
Hobbies/Sports:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
2. Who is Accompanying Your Child Today?
His/Her Name

First NameLast Name
Relation
Do you have legal custody of this child?

YesNo
Whom may we Thank for referring you?
List brothers/sisters with age:
General Dentist:
Last Visit Date:
Parent's Marital Status:

SingleMarriedWidowedDivorcedSeparatedPartnered
3. Parent's Information
Parent:

MotherFatherStep ParentGuardian
Name

First NameLast Name
Birthdate
E-mail*
example@example.com
Cell #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Employer
Work Phone #

Area CodePhone Number
Social Security #
Drivers License
Parent:

MotherFatherStep ParentGuardian
Name

First NameLast Name
Birthdate
E-mail*
example@example.com
Cell #

Area CodePhone Number
Home Phone #

Area CodePhone Number
Employer
Work Phone #

Area CodePhone Number
Social Security #
Drivers License
4. Person Responsible For Account
Name

First NameLast Name
Relation
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #

Area CodePhone Number
Driver's Licence
Employer:
Work #

Area CodePhone Number
Ext:
Social Security #:
Who is responsible for making appointments?
Name

First NameLast Name
Home #

Area CodePhone Number
Work #

Area CodePhone Number
Ext:
5. Orthodontic Insurance
Primary
Orthodontic Coverage

YesNo
Dental Coverage

YesNo
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Policy Owner's Name
Relationship to Patient
Policy Owner's Birthdate

MonthDayYear
Date
Socials Security #
Policy Owner's Employer:
Secondary
Orthodontic Coverage

YesNo
Dental Coverage

YesNo
Insurance Company Name
Insurance Company Phone #

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Policy Owner's Name
Relationship to Patient
Policy's Owner's Birthdate

MonthDayYear
Date
Social Security #
Policy's Owner's Employer
6. Orthodontic History
What are the main concerns you would like orthodontics to accomplish?
Has your child ever been evaluated or had orthodontic treatment before?

YesNo
Have there been any injuries to the face, mouth, teeth or chin?*

YesNo
List any musical instruments played:
Have adenoids or tonsils been removed?*

YesNo
Has your child been informed of any missing or extra permanent teeth?

YesNo
Has your child ever had pain/tenderness in his/her jaw joint? (TMJ, TMD)?*

YesNo
Does your child brush his/her teeth daily?*

YesNo
Does your child floss his/her teeth daily?

YesNo
Child's Physician
Phone Number

Area CodePhone Number
Date of Last Visit

MonthDayYear
Date
Is your child currently under the care of a physician?

YesNo
Has puberty begun?

YesNo
Has menstruation begun? (girls)

YesNo
Have you ever taken Fosamax, or any other bisphosponate?*

YesNo
If yes, when?
Please describe your physical health

GoodFairPoor
Please list all the drugs that your child is currently taking:
Please list any other drugs/things that your child is allergic to:
7. Has your child ever had any of the following medical problems?
Abnormal Bleeding*

YesNo
ADD/ADHD*

YesNo
Allergies to any Drugs*

YesNo
Allergies to Latex/Metals*

YesNo
Allergies to Plastic*

YesNo
Any Hospital Stays*

YesNo
Any Operations*

YesNo
Artificial Bones/Joints/Valves*

YesNo
Asperger Syndrome*

YesNo
Asthma*

YesNo
Autism*

YesNo
Cancer*

YesNo
Congenital Heart Defect*

YesNo
Convulsions/Epilepsy*

YesNo
Diabetes*

YesNo
Handicaps/Disabilities*

YesNo
Hearing Impairment*

YesNo
Heart Murmur*

YesNo
Hemophilia*

YesNo
Hepatitis*

YesNo
HIV +/AIDS*

YesNo
Kidney Problems*

YesNo
Liver Problems*

YesNo
Lupus*

YesNo
Rheumatic/Scarlet Fever*

YesNo
Sickle Cell Disease/Traits*

YesNo
Tuberculosis (TB)*

YesNo
Please discuss any medical problems that your child has ever had.
8. Does/Did your child have any of the following habits?
Clenching/Grinding Teeth

YesNo
Lip Sucking/Biting

YesNo
Mouth Breather

YesNo
Nail Biting

YesNo
Nursing Bottle

YesNo
Speech Problems

YesNo
Thumb/Finger Sucking

YesNo
Tongue Thrust

YesNo
A neighbor or relative not living with you.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agree to Terms

I understand that the information I have given today is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need. If this office accepts insurance, I assign directly to Dr Suliman. all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
My method of payment will be:
Signature of Parent or Guardian

Clear
Date
Thank you for filling out this form completely.
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.
Signature

Clear
Date
Initials
Should be Empty:

Welcome to Suliman Orthodontics

1. Tell Us About Your Child

2. Who is Accompanying Your Child Today?

3. Parent's Information

4. Person Responsible For Account

5. Orthodontic Insurance

6. Orthodontic History

7. Has your child ever had any of the following medical problems?

8. Does/Did your child have any of the following habits?